BY JAMES F. SMITH, JR.
In the United States, four Jesuit universities have medical schools. But what makes them Jesuit medical schools?
All four promote cura personalis as a defining characteristic of their curricula and of the relationship of the institution to its students. This emphasis makes good sense. As Barton Geger, S.J., has shown, “care of the whole person” has been a keynote in Jesuit higher education in recent decades, and given that medical education is meant to prepare people to provide care, it would be especially odd if these institutions did not highlight this Jesuit ideal. Yet it’s one thing to highlight an ideal and another thing to incorporate one into an institution’s academic genome and bring it to life. And this is where Jesuit medical schools should do better—and perhaps lead the way for other medical schools, not to mention professional schools in other academic disciplines.
I propose two significant reforms that could serve as measures of how Jesuit medical schools practice cura personalis and markers of their Jesuit mission. First, in place of tiered grading systems, Jesuit medical schools should introduce a “credit/no credit” system that replaces the implicit goal of “making the grade” with the explicit goal of “being the best I can uniquely be.” Second, these institutions should reform the curriculum so students can create curricular pathways that enable them to develop individualized areas of interest and distinction, pursuing personal, humanistic, and spiritual formation that sustains them in the work of caring for others throughout their careers. Taken together, these two reforms would allow medical students to accumulate the competencies and proficiencies necessary for the practice of medicine, while preparing them to be better physicians, I believe, than our current systems allow.
Studies have shown that tiered grading—whether in the form of letter grades, percentages, class rankings, or qualifying terms such as “honors,” “pass,” or “satisfactory”—is associated with undesirable outcomes such as stress, anxiety, burnout, unhealthy competition, unprofessional behaviors, erosion of group cohesiveness, and inappropriate motivational development. It also promotes racial and ethnic disparities. Tiered grades are assigned, earned, or distributed in variable fashion, even within the same medical school. Further, since there is no shared standard across medical schools—whether Jesuit or not—it is not surprising that tiered grading is considered unfair by a significant number of medical students. While many U.S. medical schools have moved to non-tiered grading systems in the classroom-based portion of medical education, most continue to use tiered grading in the clinical portion of their training. Ironically, it is in these clinical years of education that tiered grading appears to be the most variable, the vaguest, and the most visibly associated with racial and ethnic disparity.
Class of 2023 medical students at Georgetown University Medical Center recite the Hippocratic Oath. Photo courtesy Georgetown University. Photo courtesy of Georgetown University.
Tiered grading has been advanced as a motivator for students to strive for academic excellence, as an aid to residency program directors in the selection of trainees following medical school, and as a method to expose students to the stresses of medical practice they will encounter upon graduation. But there is no consensus that tiered grading offers appropriate motivation nor that it reliably assists residency program directors charged with selecting a diverse, dedicated, successful group of residents. In application, tiered grading operates more like professional hazing than preparation for the stress of medical practice, because it exploits fear of humiliation attributed to low academic performance as, somehow, a necessary emotion in the steps toward professional identity and effective practice. These ingrained perceptions of tiered grading as a necessary component in the formation of physicians are born out of academic orthodoxy rather than evidence-based pedagogies focused on the practice of safe, effective, humanistic and contemporary medicine.
Consequently, the persistence of tiered grading in medical education promotes “care for the status quo” much more effectively than “care for the whole person.”
To be clear, I do not believe standards in Jesuit medical schools should be lowered or that it is unnecessary to test students’ understanding and skills. Certainly, Jesuit medical education should be challenging and rigorous. Indeed, testing in and of itself promotes learning and signals to the public the professional imperative to assure competency and proficiency. But this can be accomplished in medical education with a “credit/no credit” grading system, applied consistently and fairly throughout the whole course of medical education. Such a system would emphasize the cognitive and technical competencies necessary for progression through, and ultimate graduation from, the medical curriculum, independent of the performance of peers. Avoiding the apparent finality and pejorative connotations of “fail” as an outcome, a “no credit” designation implicitly anticipates eventual competency acquisition at some time in the future when competency is demonstrated and “credit” awarded, even if personalized remediation along the way is necessary. As part of a practice of cura personalis, this should be medical schools’ commitment to their students, and ultimately to the patients for which they will care.
My second proposal for reform—enabling students to choose curricular pathways that enable them to develop individualized areas of distinction—would also advance cura personalis by personalizing medical training and introducing a variable, individualized length of academic activity leading to the Doctor of Medicine degree. The lock-step paradigm of the current medical school curriculum has long been the subject of debate, but innovative attempts at modifying the curriculum have been slow. Accreditation standards currently require at least 130 weeks of structured medical education. In most medical schools, this translates into a 4-year curriculum embedded in an academic calendar. However, in recognition of the various academic backgrounds of our students, which include the arts, literature, history, philosophy, religion and social sciences, creating room for a personalized curriculum will require shifting from an emphasis on physician-scientists to physician-humanists. This will likely require a comprehensive and courageous review of the need for the biomedical science-heavy curriculum characteristically found in most medical schools, especially during the pre-clinical years of education.
Flexibility in the duration of the total curriculum leading to the Doctor of Medicine degree, by accumulation of credits rather than a rigid four-year course of study, would offer several advantages for our students. Professional and personal aspirations would be better balanced. Students could more easily pursue various fields of interest to them while in medical school, fields within and beyond the biomedical sciences if they so choose—but all important for the practice of contemporary medicine. Additionally, family and social considerations, commonly subordinated to the culture of medical academia that values conformity and academic performance over the unique narratives and individual aspirations, would find a more personal, welcoming and balanced educational environment. Such an educational environment should be the hallmark of cura personalis.
If Jesuit medical schools are to invoke cura personalis as more than a sentiment, but as the true foundation of their relationship with their students, they must recognize the imperatives involved and act courageously. Our students, and their future patients, deserve this.
James F. Smith, Jr., is professor of Medical Education and Medical Humanities at Creighton University School of Medicine. He holds a medical doctorate from Saint Louis University and a bioethics doctorate from Loyola University Chicago.
The featured cover photo (above) is courtesy of the Catholic Sun.